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Short Form Date of election if applicable: ❑ Amendment (Explain Below) For Official Use Only
(Month, Day, Year) JAN 31 2019
CITY CLERK
ClyY 3►K�wrUNT
1. Statement Covers Calendar Year 20 18 ;' �
2. Officeholder or Candidate Information 3. Office Sought or Held
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
COREY CALAYCAY CITY COUNCILMEMBER
STREETADDRESS JURISDICTION (LOCATION) I DISTRICT NUMBER
(IF APPLICABLE)
1555 WEST BASE LINE ROAD CITY OF CLAREMONT
CITY STATE ZIP CODE
CLAREMONT CA 91711
AREACODE/DAYTIME PHONE NUMBER OPTIONAL FAX/ E-MAIL ADDRESS
4. Committee Information
List all committees of which you have knowledge that are primarily formed to receive contributions or to make expenditures on behalf of your candidacy.
COMMITTEE NAME AND I.D. NUMBER COMMITTEE ADDRESS NAME OF TREASURER
N/A
5. Verification
I declare under penalty of perjury that to the best of my knowledge I anticipate that I will receive less than $2 .000 and that I will spend less than $2,000 during the calendar year and that I have
used all reasonable diligence in preparing this statement. I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
JANUARY 31, 2019
Executed on By
SIGNATURE OF OFFICEHOL ER OR C DIDATE
Clear Form 1 I Print Form
1 _l FPPC Form 470/470 Supplement (Jan/2016)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov